Implementing Total Joint Arthroplasty Same Day Discharge Programs in Hospital & ASC Settings

TJA Blog Series Part I


By 2025, the annual number of total knee arthroplasty is predicted to increase by 110% to 1,272,000 replacements. Similarly, the demand for hip arthroplasty is also projected to spike, increasing by 75% to 652,000 replacements. With this in mind, coronavirus (COVID-19) has only further complicated an already very complex issue. Hospitals and ambulatory surgery centers (ASCs) are left pondering how to continue surgeries safely and sustain the post-surge, all while abiding by COVID-19 restrictions. The urgency to convert total joint arthroplasty (TJA) procedures to same day discharge (SDD) clinical pathways has never been more critical than it is now. But where does the healthcare organization begin? How can hospitals and ASCs overcome the standard barriers associated with migrating to outpatient surgeries while also addressing the new hurdles COVID-19 has introduced?


Now is Not the Time to Cancel Surgeries but to Shift Them


Hospitals do not relish the idea of canceling surgeries - the highest driver of revenue - but in some cases, leadership may feel this is their only option. More often than not, this CAN be avoided by doing the day-to-day in a new way, working towards SDD, and shifting a large portion of cases from inpatient to outpatient.


The overall response across the U.S. regarding elective surgeries varies:


CEO of Intermountain Healthcare, Marc Harrison, M.D., shared how his team is responding to this crisis in an interview with HealthcareDive, “While most joint replacements historically require an overnight stay, the 24-hospital system is performing half of the joint replacements in its St. George, Utah, locations as outpatient procedures to free up beds and staff.”


Most Bay Area hospitals, including John Muir Health, are prioritizing surgerys on a case by case basis and rescheduling those that can wait. Chief Nursing Executive with John Muir Health, Michelle Lopes says, "For example, for some patients, a total hip replacement, if they're completely immobile and unable to move could be urgent."


While COVID-19 positive cases are surging in certain areas, some hospitals are opting to pause elective procedures that require an overnight stay.


Our Experiences with Implementing TJA & SDD Programs


Sharing our experiences with implementing these practices is vital to decrease the learning curve and quickly achieve the objectives of SDD. Sullivan Healthcare Consulting (SHC) understands how to put our expertise into action efficiently.


  • Limited workflow planning at sufficient detail levels.

  • Back-up planning is necessary to meet the needs of an unexpected overnight stay.

  • Strong leadership is needed for close coordination and control to avoid clinician confusion and poor outcomes.

  • Meeting dual objectives of COVID-19 surge times and sustaining them long-term.

  • Creativity and innovative thinking are required to resolve recovery space and staffing during. COVID-19 surge times.

  • Establishing a reliable process and outcome metrics.


Leading Practices Identified & Implemented by SHC


There is limited research in the surgical community concerning the shift from inpatient to outpatient care, with minimal A1 evidence supporting its efficacy and even less information available on best approaches and caveats to avoid. While “best practices” typically come from academic medical centers, they simply do not have the bandwidth to do well-controlled studies at this time.


With our decades of hands-on experience and national perspective, SHC’s experts are on the cutting edge of helping hospitals and ASCs survive these interesting times by guiding them toward successful transitions to SDD. Our leading practices and hands on approaches have been calibrated over many years in the perioperative space and are currently being implemented across the country.


Michael Ast, MD, an orthopedic surgeon and assistant professor of orthopedic surgery at Hospital for Special Surgery in New York City, recently shared with Becker's ASC Review the first step in shifting total joint replacement cases to outpatient.


"First is the development and implementation of strong, structured protocols that are evidenced-based for successful outpatient joint replacement. These protocols should specifically focus on patient selection, pain management, and blood and fluid management."


SHC experts know the right “monitors and metrics” to employ to assess and redirect leading practices.We use our vast industry knowledge to hone in on what is working and what needs to be tweaked.


Practices Identified Along the Clinical Pathway


To learn more about our perioperative and/or ASC services and how SHC can shift appropriate TJR cases to outpatient and achieve SDD, contact us today.


Additional Reading


Randy Heiser is the President of Sullivan Healthcare Consulting. Randy has been a hospital consultant since 1983 and has specialized in perioperative consulting since 1992. He has directed more than 500 surgery department operational improvement studies (and participated in an additional 350) in programs ranging from small community hospitals and freestanding surgery centers to some of the largest university hospitals in the U.S. He was instrumental in the design, development and implementation of the Surgery Benchmark Program that has been used by more than 280 hospitals. He has also participated in the design of several proprietary surgery scheduling information systems currently available in North America.

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